Pulmonary Disorders II

incorrect; Answer B is correct). Antimicrobial treatment

should be initiated if (1) all three cardinal symptoms of

an ECOPD (increased dyspnea, increased sputum pro-

duction, and increased sputum purulence) are present;

(2) two of the three cardinal signs are present, with

increased sputum purulence as one of the symptoms; or

(3) the patient requires noninvasive or invasive ventila-

tion. This patient has no indication for antimicrobials

(Answers A and C are incorrect).

Answer: D

Although the GOLD-recommended dose of steroids

for an ECOPD is prednisone 40 mg orally (or intrave-

nously), some studies that included populations of ICU

patients have shown higher doses may be needed or

may be tolerated with some increase in adverse effects.

Currently, doses higher than prednisone 40 mg have not

been linked to increased mortality (Answer A is incor-

rect). A recent investigation identified significant racial

bias in the use of peripheral Sao2 because of frequent

overestimation of Sao2 compared with a direct ABG

measurement for patients with darker skin tones. This

answer is incorrect because the publication did not

investigate patient outcomes. This patient has a higher

Spo2 measure than the patients in the study (92%–96%),

who had a high rate of hypoxemia identified on ABG.

Answer C is incorrect because no specific dose of mac-

rolide has been linked to mortality, and azithromycin

500 mg intravenously once is the recommended load-

ing dose. Answer D is correct because titrating oxygen

therapy to peripheral Sao2 greater than 88%–92% has

been linked to mortality. The correct intervention would

have been to decrease the Fio2 when the patient had an

Sao2 greater than 92%.